It’s become a bit of a motherhood statement that “something must be done about The Bush”;  but precisely what?

Set against this is a popular political stereotype of underworked overpaid city based medics having daily “chatty-poo’s” with the worried well – surely not?

So when an opportunity arose for volunteers to travel west to Emerald, courtesy of the Rural Division of General Practice, based on a Commonwealth initiative, my lady wife decided that I should duly put my hand up.

Of course that was several years ago, and something of a steep learning curve for any psychiatrist for whom the normal established routine was that patients visited me; central Queensland was to become a personal “medical tree change”, and I was met by all and sundry with a studied polite curiosity; initially a few “tried and trusted patients” arrived, complete with two page referral letters (no “please see and advise”, or “could this bloke have a bit of psychotherapy” out here); there was of course the statutory “upskilling” meeting (ghastly expression) supposedly on the subject of psychopharmacology, which was something of a blow to the ego because I actually thought I was a psychotherapist, and there was even a trip round a cotton farm – all kindly meant., and well appreciated.

And then there was silence, apparently there was a drought of clinical material, I took to travelling with a good book, even several good books, and it slowly dawned upon me that my GP’s colleagues “in The Bush” didn’t really believe that I would come back, after all the previous psychiatrists hadn’t, or had only turned up if there were actually patients in the appointment book, all of which I learnt was somewhat the wrong way round.

The trouble with all good ideas, especially where The Bush is concerned, is that the folk in “The Bush” never really feel they have been adequately consulted, except at elections, when total strangers emerge from executive jets, clasping dustless but symbolic akubra’s promising everything, including the kitchen sink, and then disappear.   The lady at the motel, with whom I was sharing my problems, understood the whole situation immediately, it was the old “school tuckshop syndrome”; she went on to explain what she meant, describing a group of diehards who liked nothing more than to meet occasionally in holy huddles around weak tea and lamingtons, complaining how much they were misunderstood and overworked and taken for granted by all the other parents.  And then that dreaded day arrived when a new group of “volunteers” wandered into the tuck shop, and they were promptly ignored for their trouble because “they didn’t really know the ropes” and, of course, “if a job’s worth doing you should basically do it yourself”.

So after this well placed piece of CBT I persisted, though I confess beginning a new practice when I was nearly sixty was a sure sign of insanity, after all the Oxford English Dictionary defines such as being “a failure to subscribe to commonly held beliefs”.  Persistence has it’s own rewards however, and I sometimes now find myself with a dozen or so new referrals, I drive out to exciting sounding places like Clermont Springsure and even Blackwater, and there I meet any number of those “fellow Australian’s” (now where have I heard that before?!) who are genuinely struggling in the face of overwhelming odds – but they have a great deal to teach, and it’s my belief that projects such as this should be encouraged, promoted, and even expanded upon.  Too often “good ideas for The Bush die, mostly from “apathy”, that well known contagion that works on the philosophy that “it’s a good idea but what is somebody else going to do about it?”

A visit or two ago I left my book on the outgoing plane, something I fear that might be coming a habit, maybe even the early stages of “old timers disease”, but I knew well enough, from travel up and down the eastern seaboard of Australia that the chances I of me seeing that particular tome again was zilch; but I was entirely wrong, as I often am out here “in The Bush”; I was booking in for my return flight back to Brisbane, and a member of the local airport staff took one look at me, reached under the counter and returned the book to me with the words “you shouldn’t be making a habit of this Doc…see you next time!”

Perhaps I have at last arrived, at least I feel I belong, but I am sorry, I am not going to buy one of those bloody akubra’s!

The tools are my emotions

Some never unpacked

Some looking for a place to belong, some hung against the wall

Some etched in white painted lines

Some unpacked lying on the floor

Some never taken out of the box

They could even come with an instruction manual

A manual might have been read

By somebody else

It could come with a label, somebody else’s label

Never be angry, anger is bad

Anger is against the will of God

Anger is a product of weakness, anger leads to loss of control

Yet all the emotional tools must be selected by evolution

Darwin like

The survival of the fittest

Like filing clerks, these emotional tools attach themselves, to object loss object gain object change

Like filing clerks they assist in processing those elusive cognitive functions

They allow the incident the event the change to be filed away

Truthfully, hopefully,

But after the filing the emotional tool is released, granted freedom, enriched by the experience

Returned to its right and proper place hanging on the wall of the shed I call my mind.

The changes, the events, the incidents are never forgotten

Merely filed,

The filing cabinets roll back into the darkness of unconsciousness

The filing clerks release the truth and empower the process

Filing clerks know what isn’t true, the filing is incomplete, it cannot let go

Slowly the process becomes dysfunctional, neurotic,

There is no truth only illusion

The filing clerk is retained in the past,

On permanent loan on lend lease

Leaving the mind a little bit more powerless,

The wall in the toolshed emptier and when the walls are completely empty there is complete impotence, PTSD

When similar change takes place

Further along the pathway of our living

The emotional filing clerk is summoned

But the wall is empty, the clerk is AWOL, absent without leave

The apparently new becomes the what was,

Past and present intertwined

Indivisible, searching for release one from the other

Release from impotence

For the past takes precedence over the present,

The future becomes the present

The truth must be found

The truth must be filed

The filing clerk must be relieved again

The truth cannot be left in a pending tray, wrapped in brown paper and string

But when filing is finally achieved

The emotional tool can be returned,

Power can be regained, the present can be confronted,

Change can then be managed

And there is no need to re-visit the past

Again

And again

And again.

I am suffering from stress

I am suffering from the weather

I am wet because it rained

I am wet because I left my umbrella at home and did not listen to the weather forecast?

I am not suffering from stress

I am in distress because my outer world is too full of change

My inner world is bereft of resources to handle such change

I know because I have checked the lights on my emotional dashboard they are all turned on and I am switched off

My rest is disturbed and fatigue is the order of the day

My distractability is infinite

What short term memory

My sadness is transmitted to my tear ducts and translated into tears

My frustration with self is displaced into crankiness with others

My sense of melancholy cloaks me like a smog

That which once brought me joy has all the tastelessness of dampened stale bread

And a knock on the door or the ring of the telephone is now my enemy

There have been times when I have tried to say “I love you”

But all I hear is silence

I try to reach out my arms to hug and be hugged

But they fail to respond to my bidding

When I open my eyes in the morning to check whether I am still here

I have some passing doubts

Perhaps I should learn to prioritise the changes that are occurring in my life perhaps

Perhaps I should base my decisions on the opinions of those I respect perhaps

Perhaps approved and being liked should not be the ultimate yardstick of my journey perhaps

Perhaps I should learn to set boundaries perhaps

Perhaps I should learn to let my yes be yes and my no be no perhaps

Perhaps I should pull myself away from the gravitational pull of my guilt perhaps

I will set for myself new goals

I will put myself on my own priority list

I will service myself and my living

Perhaps I am not suffering from stress after all

I am distressed, that is part of the human condition, but in order to be in control, in order to feel a sense of belonging, sometimes I have to tread the path that is wilderness

The rain is still falling and the dams are still filling…

Seven patients have failed to attend, four of them had been new referrals, all had received telephone reminders, all possessed telephones… all had discovered more important on their priority list at that particular time, and all had failed to indicate that it was their intention not to attend – nothing particularly unusual about that.

However one young man had managed to fit me in to his busy schedule, albeit running late, certainly unapologetically so; he had visited a family doctor, any family doctor would have done, complaining of “depression” or “stress” or possibly even both.   The doctor had given him a “sample pack” of one of the latest in a long line of SSRI/SNRI’s, and a referral letter was addressed to the first psychiatrist on the list who had an available appointment, the first cab off the rank as it were.  The young man had made three appointments from the list he’d been given, and of course, had failed to cancel the other two.  Nothing unusual about that.

In spite of this young man’s lateness, somewhat atypically, I decided to see him anyway, after all, as he himself said, the folk who had chosen to arrive on time for their appointments would not mind waiting until he had completed his.  Nothing unusual about that.

The letter from the family doctor was one of the traditional round robins – “this young lad whom I haven’t seen previously needs a bit of psychotherapy…please see and advise…”; that was all it said.

So the stage had been set, as had been the expectancies – a bit of that “talking treatment”, a bit like Dr. Phil, a bit like Dr. Frasier, a visit or two should do the trick nicely; maybe a few wise words to garnish the appointment along the way, after all it couldn’t do any harm it will be cheap, it might even be free.

I introduced myself and tried to explain the nature of “the shop” the young man had entered and why I didn’t actually possess a couch.  (Hollow laugh).

Since in excess of eighty percent of new referrals (according to a survey I recently conducted in my own practice) did not appear to have the slightest idea what the difference between a psychologist and a psychiatrist might be, let alone the differences between counselling analysis and psychotherapy, I have always felt that such basic information is essential, though clearly this young man didn’t, he just wanted to “turn his life around”.  Whether I was medically qualified or not, was about as relevant as whether I practiced Callithumpian therapies with hot rocks in tepee’s on the peaks of tall mountains.

I endeavoured to persist in my explanations, but it had been a very long week; I applauded his decision to take time out to examine the direction in which his life was travelling, I encouraged him in his belief that pills alone didn’t have all the answers, I outlined my reality that “quick fixes” are in short supply, I pointed out that happiness for happiness’ sake was at times a deceptive goal…and of course as I travelled down this pathway of explanation I knew I was losing him, but I persisted, after all all of the above can be effectively replaced, by those with adequate motivation, with a few regular attendances, possibly some homework, and a small payment which to him would have been around twenty dollars a visit, that is the price of forty cigarettes.   At this point I’d lost the young man completely.

The young man looked totally horrified – “I just wanted to turn my life around… you mean I’ll have to pay for it… I’ll have to come back…” he exited state left, and I never saw him again, but he did call back several days later to pick up his exceedingly flash mobile phone that he’d dropped behind the chair in which he’d been sitting…

And so the fires keep burning around Surfers Paradise, possibly within Paradise as well.

This is not an uncommon story from within community-based psychiatry, a story that could be multiplied over and over again, a story that presents a challenge in faith in understanding the true nature of therapy and their place within our community.

The community continues to be bamboozled by media messages that confuse fact fiction and expectancies that have sometimes not changed since Jack climbed up the beanstalk and met the giant.

The family doctor is fighting for his clinical life in attempting to establish a role in the midst of managed patient care, Government controls, increasing specialist takeovers, the Indemnity crisis, mounds of paper work, and lack of loyalty from all sides.

The therapy industry has become threatened in the face of the multi-national pharmaceutical industries and seeks to cut out it’s own niche market; psychiatrists are left feeling disenfranchised, hopeless and helpless with long-term roles under threat and indifference generally speaking as a response from the powers that be.

Quo Vardis.

So perhaps it is more than a little surprising to learn that all forms of gambling are on the increase.

Now, I’m not about to wax indignant on the horrors of the seven deadly sins – merely to remark on the apparent contradiction that when people have less they seem more prepared to take unnecessary risks to gain more, in spite of the reality that poor bookies are a rare breed.

Gamblers, or rather compulsive gamblers, don’t make it frequently to the psychiatrist, tending to be more secretive about their behaviour than many others stricken by addictive behaviour.

Compulsive gamblers are by nature confirmed optimists.

They live in that constant hope that tomorrow they will win back all their money with enough interest to justify the initial wager.

In addition, the compulsive gambler has a remarkable capacity to deny the reality of how much he has lost, especially when the rush is on, the roulette wheel is spinning and the adrenalin is coursing through his veins, giving him a ‘high’ equal to any other drug.

At that particular point he would probably sell his grandmother for just one more flutter.

It is debatable whether compulsive gambling is an illness.  But there can be little doubt as to the destruction that it wreaks on the families of the many sufferers.

To those who stand outside such behaviour it seems amazing that anyone should deny logic and waste so much for so little in such a short space of time.

In the past, gambling has been portrayed either as the sport of the idle rich wearing white dinner jackets and smoking cheroots or by the small man in the dirty raincoat surreptitiously sneaking a few crumpled notes to an equally shady character outside the pub.

Of course, these are very restricted word pictures of a problem that extends to every section of our community, and whether it be the odd Scratch It or a genteel game of bingo, gambling is part of our lifestyle.

That is not to say that it doesn’t bring a great number of folk a great deal of enjoyment without necessarily doing anybody any harm.

But having said that, this is the tip of the iceberg.

To explain this it’s probably easier to look at the lifestyle of a once wealthy man who, for the sake of anonymity, we’ll call him Jim.

Jim had earned his money in the production of a minor engineering component that no-one else much wanted to make.

He duly made his pile and burned the candle at both ends.

Eventually he was told that he had to retire, and not being particularly elderly he came to live in the sunny climes of south-east Queensland.

When he arrived he became deeply involved in building his new home and planting out his garden.

He ended up with what most of us think we most desire – peace and quiet, and freedom to do precisely what we’d like without having to go to work.

In other words, from being highly stressed and well rewarded he became totally without a goal, without stimulus, and his life had little meaning.

Jim was not well programmed for sitting around and doing nothing.

He wasn’t into painting sunsets, and working for Meals on Wheels wasn’t his style, so one evening he wandered over to the local gaming establishment and within a short time he had lost $400,000.  What’s more, he didn’t stop there.  He went back again and again, and although he occasionally had winnings in the order of tens of thousands of dollars he lost a great deal more than he won.

He eventually sought help from Gamblers Anonymous only after his wife had left him and the house was sold.

Why had Jim committed this unconscious, but for him extremely exciting, act of sabotage on his life since he was clearly not a victim of stress?

Jim could be said to be suffering from an addictive personality, which had been an economic advantage while he was at work.

But when that was taken away from him he was left without any goals and, whether unconsciously or otherwise, he provided himself with a mechanism which gave an immediate buzz, as well as providing him with a new-found reason for going back to work.

Challenging and helping folk like Jim is the day-to-day job of Gamblers Anonymous.

But the first stage we must all acknowledge is that there is one thing worse than being over-stressed and that is to be under-stimulated.

If we find ourselves in this state we have a built-in escape button, and one of these is provided by gambling.

I have to admit that I always thought it a little harsh, but that was before the days when I learnt that sympathy and empathy might sound roughly the same word but are a long way apart in terms of their meaning.

Practically speaking I came to learn what my supervisors tee-shirt was actually telling me; our daughter, little Lucy-Clare, had the misfortune to be born with what is known as congenital heart disease, a pump in her chest resembled a badly wired colander, if such a metaphor doesn’t sound too outrageous; the reaction among the medical fraternity in which I worked was a polarised one, stretching across all the many faces and moods that human experience can muster.

One swing of the pendulum was symptomatised by a one time thoracic surgeon (his father had been taught by the great Karl Gustaff Jung) who had rejected his earlier training and gone into the world of psychiatry in general, and psychotherapy in particular; he was, and as far as I know still is, a beautiful soul, he exuded sympathy from every pore, yet somehow every time he wished to express sympathy for the situation our family found ourselves in I felt more and more frustrated, and indeed more and more anxious, for he had been a thoracic surgeon, so that maybe he knew a great deal more than could go wrong than I did.

At the other end of the scale was Mary, Mary was an exceedingly tough American psychoanalyst, an inappropriate blink of the eye, the manner in which the arms were crossed over the chest, let alone the words that I used were all grist to the mill of her interpretations.  Frankly in many ways Mary terrified me, which would have horrified Mary because underneath it all she really was a very caring soul; a few days before our family’s trip to London, for the fatal day, for the rendezvous for open heart surgery, I observed Mary arrive at our front door; I was terrified, I perceived indeed expected interpretation to pour out of her, after she knocked on the door I somewhat reluctantly opened it, expecting to be showered with wisdom from on high, instead all I received was a quick smile, and she reached into her handbag and presented me with a large bottle of brandy, with the words “I guess you might be needing this” and she went upon her way.

I guess the question posed relates to which of the two therapies were the more effective, and the answer I might leave to you, gentle reader.